Nursing Elites

1. A female victim of sexual assault is being seen in the crisis center. The client states that she still feels 'as though the rape just happened yesterday,' even though it has been a few months since the incident. The appropriate nursing response is which of the following?

• A. You need to try to be realistic. The rape did not just occur.
• B. It will take some time to get over these feelings about your rape.
• C. Tell me more about the incident that causes you to feel like the rape just occurred.
• D. What do you think you can do to alleviate some of your fears about being raped again?

Correct answer: C

Rationale: The correct response is to encourage the client to talk about the event that makes them feel as though the rape just occurred. This approach can help the client process their feelings and experiences, which is crucial in dealing with trauma. Choice A is dismissive and negates the client's feelings, which can be harmful. Choice B, although acknowledging the time needed to heal, does not actively address the client's current feelings. Choice D shifts the focus to future fears rather than addressing the client's current emotional state.

2. A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. What is the nurse's priority action?

• A. Encourage the client to talk about the trauma.
• B. Help the client to focus on the present.
• C. Administer prescribed anti-anxiety medication.
• D. Leave the client alone to work through the flashback.

Correct answer: B

Rationale: The priority action is to help the client focus on the present (B), which can reduce the intensity of the flashback. Encouraging discussion of the trauma (A) should be done when the client is not actively experiencing a flashback. While medication (C) may be necessary, it is not the first priority in this situation. Leaving the client alone (D) is not appropriate as they need support to manage the flashback.

3. A nurse is caring for a client with depression who is prescribed fluoxetine (Prozac). The client reports difficulty sleeping. What is the most appropriate nursing intervention?

• A. Encourage the client to take short naps during the day.
• B. Suggest the client drink a warm beverage before bedtime.
• C. Recommend the client exercise immediately before bedtime.
• D. Advise the client to take a sleep aid nightly.

Correct answer: B

Rationale: The most appropriate nursing intervention for a client with difficulty sleeping due to depression and prescribed fluoxetine is to suggest the client drink a warm beverage before bedtime. This intervention can promote relaxation and help establish a bedtime routine, potentially improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep schedule. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be done under the guidance of a healthcare provider due to potential interactions with fluoxetine.

4. Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend a daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?

• A. Medication non-compliance.
• B. Number of bathroom facilities.
• C. Infection control.
• D. Acting out behaviors.

Correct answer: C

Rationale: The priority issue that the RN should address is infection control. The unsanitary conditions in the bathroom, with sputum on the walls, urine in the sink and on the floors, and the toilet clogged with tissue, paper towels, and feces, pose a significant health risk to all residents and staff. Addressing infection control is crucial to prevent the spread of diseases and ensure the well-being of everyone in the facility. Medication non-compliance is important but not the priority in this situation. The number of bathroom facilities, while relevant, is not the immediate concern when faced with unsanitary conditions. Acting out behaviors, though a valid concern in mental health settings, are not the priority when faced with such unsanitary and potentially infectious conditions.

5. A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which action is most important for the nurse to implement?

• A. Calmly approach the client and remove the chair from the client.
• B. Obtain staff assistance to help diffuse the escalating situation.
• C. Offer feedback about the client's behavior.
• D. Summon the hospital security guards as a 'show of force.'

Correct answer: B

Rationale: In a situation where a client is displaying aggressive behavior, the most important action for the nurse to implement is to obtain staff assistance to help diffuse the escalating situation. This approach ensures the safety of all individuals involved and prevents the situation from escalating further. Calmly approaching the client and removing the chair directly could agitate the client further and pose a risk to the nurse. Offering feedback about the client's behavior may not address the immediate safety concerns. Summoning hospital security guards as a 'show of force' should be a last resort after other de-escalation attempts have failed, as it may further provoke the client.

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